As a counsellor for families of psychiatric patients, I have come across many instances of questionable behaviour among psychiatrists. While it may be difficult to describe them outright unethical, they seem to prevent people from getting effective psychiatric help, and increase the burden carried by patients and their families.

Surekha was the only earning member of an educated Indian middle-class family. When she lost her father in her final year of college, she was forced to look for a job in order to shoulder family responsibilities. Luckily for her, it was not difficult to find a job in a private company in Delhi, though her lack of experience meant she had to be content with a low salary.

The family consisted of three sisters (of which Surekha was the oldest), an elder brother, and an ageing mother. The brother suffered from schizophrenia, a devastating illness that affects one per cent of the population. In this condition both patient and family face several traumatic situations. The illness triggers off uncontrollable symptoms, in the patient, such as fragmented thoughts accompanied by hallucinations, anxieties and, very often, violence. Without an understanding of the nature of this illness, the family is unable to handle such behaviour and help the person get better. The majority of patients suffering from schizophrenia can function normally if the problem is detected early, and they are given adequate treatment and counselling along with psychotropic medication.

Like Surekha, there are hundreds of young men and women who are facing the challenge of handling a family member suffering from schizophrenia. In the beginning the families try to deal with the situation within the family environment but when there are frequent bouts of violence they must seek psychiatric help.

Thus begins their ordeal of dealing with endless trips to psychiatrists. Many private practitioners do not reveal facts to the patients as they feel they may lose their regular income and hence keep giving false assurances like “there is no problem”, “continue the same medication”, “do yoga”, “come next week”, etc.

As a result, people are unsatisfied with the treatment and go from one doctor to another, seeking treatments from various doctors and in various hospitals. People who could have been treated successfully if the problem had been identified early end up chronically mentally ill. Some are abandoned in asylums by their families.

Schizophrenia does not have a definite cure; it can only be contained and requires specialised care and treatment in hospital. Thereafter, when the patient is stabilised he or she requires constant medication along with counselling and some kind of vocational training which cannot be done in a family situation. They need to be handled in a halfway home where everything is provided in a balanced manner. Such sustained, specialised care is available in very few halfway homes. Those that offer such services are not affordable for middle-class families like that of Surekha.

For Surekha, the challenge of looking after an affected elder brother, two younger sisters and an ageing mother was very traumatic. She walked into my home one evening to ask for help with her brother who was showing acute symptoms of schizophrenia. He had stopped going out of the house, had become highly abusive, and displayed demanding and violent behaviour. She looked harassed and wept bitterly, telling me she saw no charm in living and wanted to commit suicide.

I advised her not to take that extreme step. I told her that years earlier I too had been in a similar situation, Today, I said, I was there to help her out, as a counsellor for families with such problems. I suggested that she talk to a psychiatrist and get her brother sedated in order to admit him to a hospital. Unfortunately in Delhi only private hospitals have facilities for dealing with emergencies like sending an ambulance with wardens to handle psychotic patients. A reference from a psychiatrist simplifies matters.

The next day, I explained the case to a reputed psychiatrist. I requested him not to charge Surekha since she was only seeking guidance on how to admit her brother to the hospital, and the people she could approach for this work. On enquiring from Surekha later, I found out that the psychiatrist had charged her Rs. 450 — just to tell her to contact the concerned hospital for calling an ambulance.

Now, I understand if the patient had been taken to the doctor for treatment and the doctor had prescribed medicines after an assessment. But should a doctor charge a fee just to give simple advice?

A few weeks later, Surekha met me again. Her brother had been admitted in a prestigious but expensive hospital in Delhi. She was finding it hard to bear the costs of treatment here. I suggested that she send her brother for further treatment and rehabilitation to the National Institute of Mental Health and Science (NIMHANS) at Bangalore. It would be more affordable in the long run. However, when she asked the doctors to discharge her brother so she could take him to Bangalore, they told her that NIMHANS was a mental asylum and her brother would be mistreated there. Now, NIMHANS is a premier organisation for mental health in India. Were the doctors behaving responsibly by creating such fears in the minds of this family about such a well-known organisation? Could they offer Surekha better options?

Instead of helping Surekha make a choice that would help her brother while preventing her from going bankrupt, the doctors had created new fears and made her situation even more difficult. Was this ethical behaviour?